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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Evaluate pediatric immunization records and identify missing immunizations

  • Recognize appropriate contraindications for holding immunizations until a subsequent visit

  • Develop an appropriate plan for vaccine catch-up including selection of appropriate vaccine products for pediatric immunizations

  • Properly educate caregivers regarding premedication, adverse effects of vaccines, and vaccine controversies, such as autism

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PATIENT PRESENTATION

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Chief Complaint

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"Lately my son has been fussy and doesn't sleep very well. His forehead was warm to touch last night and I am concerned that he may be coming down with something."

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History of Present Illness

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Kyle Smith is an 18-month-old male toddler who was brought into his pediatrician's office (use today's visit as 08/01/2012) by his mother. The mother notes that her son has been irritable and demonstrates difficulty sleeping over the past few days. Additionally, she reports that he has been eating less with meals over the past few days and has been tugging on his right ear for the past day or so and has become increasingly fussy. His mother has no other complaints at this time.

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Past Medical History

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Normal spontaneous vaginal delivery (NSVD) at 37 weeks' gestation. No hospitalizations or complications since birth.

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Social History

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The patient lives at home with mother and father. He attends day care during the weekdays as both parents work full time. Siblings include a 4-year-old sister who also attends day care as well as preschool.

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Allergies/Intolerances/Adverse Drug Events

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Green gelatin ("itching" per mother)

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Medications (Current)

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Acetaminophen infant drops 130 mg PO q 6 h PRN fever, last dose given at 21:00 last night

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Immunizations

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Please see attached immunization record for this patient.

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Per mother, the patient has not experienced any adverse reactions with immunizations except for some mild erythema with the Pediarix vaccine.

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Review of Systems

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Positive for fever and decreased appetite; negative for rashes, bruises, recent trauma, or accidental falls; negative for discharge from the eyes or ear pulling; negative for nausea, vomiting, or changes in bowel or urinary patterns; positive for decreased oral intake; negative for lethargy

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Physical Examination

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General
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Irritable and fussy 18-month-old male in no acute distress

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Vital Signs
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BP 100/55 mm Hg, P 95, RR 24, T 37°C

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Weight 28 lb (12.7 kg)

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Height 33 in. (84 cm)

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IMMUNIZATION RECORD
Birthdate: 1/1/2011
Vaccine Product Name Date Given Route and Site Vaccinator Signature/Initials
Hepatitis B Recombivax HB 1/1/2011 IM ...

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